Provider Demographics
NPI:1609004910
Name:KISNER, ANGELA M (DOM, FNP-CB, BSN-RN)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:M
Last Name:KISNER
Suffix:
Gender:F
Credentials:DOM, FNP-CB, BSN-RN
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:MARIE
Other - Last Name:FREDERICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DOM, FNP-CB, BSN-RN
Mailing Address - Street 1:9805 RIO CORTO AVE SW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87121-2628
Mailing Address - Country:US
Mailing Address - Phone:505-803-3623
Mailing Address - Fax:
Practice Address - Street 1:1501 SAN PEDRO DR SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-5154
Practice Address - Country:US
Practice Address - Phone:505-265-1711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-25
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM992171100000X
NM54175261QV0200X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No171100000XOther Service ProvidersAcupuncturist
No261QV0200XAmbulatory Health Care FacilitiesClinic/CenterVA